Aetna Medicare PPO Benefits

Posted on

You may want to register for the Aetna Medicare PPO plan, but you may wonder about the benefits that you will get in this plan. You are able to read about it below where the source of information is from Aetna Medicare website.

Medicare Advantage PPO Plans

Medicare Advantage PPO plans give you permissions to be able to visit Medicare-approved providers, in or out of Aetna’s provider network, who accept Aetna’s plan terms. For specialist or hospital visits, a referral from a primary care physician is not needed by you. When providers in your plan’s network are used by you, it may cost less.

According to the Aetna Medicare website, here are some points about PPO plans.

  • It does not require you to utilize a provider network. However, if you see out-of-network providers, usually it will cost more.
  • Generally, you do not need to have a PCP or Primary Care Physician.
  • You are not required to have a referral if you want to see a specialist.
  • Monthly premiums vary by plan.
  • Medical deductible varies by plan.
  • The plan restricts what you pay out-of-pocket for medical care each year.
  • In most plans, it covers prescription drug (Rx).
  • Let’s say that plan has Rx coverage. If so, it includes Rx mail-order benefit.
  • In most plans, vision, dental and hearing coverage are provided.
  • ER and urgent care coverage worldwide are available.
  • Fitness benefit is provided through SilverSneakers.
  • In a lot of plans, over-the-counter (OTC) benefit is provided.
  • In most plans, meals-at-home program (meals delivered after an inpatient hospital or skilled nursing facility stay) is provided.

On Aetna website in an article about the difference among HMO, POS, PPO, EPO, and HDHP with HSA, PPO is the plan with the most freedom and it has pricier premiums than an HMO or POS. However, this plan permits you to be able to see specialists and out-of-network doctors without a referral. How about copays and coinsurance for in-network doctors in PPO? They are low. A PPO is a good choice for you if you know you will need more health care in the coming year and you are able to afford higher premiums.

Aetna Medicare Choice Plan (PPO) Benefits in Service Area: California: Los Angeles

It is important for you to note that benefits may different in each area and here I will give you the explanation about Aetna Medicare PPO benefits according to the Aetna Medicare.

Here are what you should know:

  • PCP or Primary Care Physician
    The option to choose a PCP is available for you. When Aetna Medicare knows how your provider is, Aetna Medicare is able to better support your care.
  • Referrals
    PPO does not require a referral from a PCP to be able to see a specialist. It is important for you to note that some providers may need a recommendation or treatment plan from your doctor to be able to see you.
  • Prior authorizations
    Your provider will work with Aetna Medicare to get approval before you get certain services or drugs.
Plan cost & information In-network Out-of-network
Monthly plan premium $90
You need to continue to pay your Medicare Part B premium
Plan deductible $0 $750
This is the amount you pay for certain services before Aetna Medicare Choice Plan or PPO starts to pay. The plan deductible happens only to certain out-of-network services.
Maximum out-of-pocket amount (does not include prescription drugs) $6,700 for in-network services $11,300 for in- and out-of-network services combined.
The most you pay for coinsurance, copays and other costs for medical services for the year. After you reach the maximum out-of-pocket, the plan pays 100% of covered medical services. Your premium and prescription drugs do not count to the maximum out-of-pocket.
Primary benefits Your costs for in-network care Your costs for out-of-network care
Hospital coverage
Inpatient hospital coverage $395 per day, days 1 to 5; $0 per day, days 6 to 90

 

You pay $0 for days 91 and beyond

40% per star after your plan deductible
The plan covers an unlimited numbers of days
Outpatient hospital observation services $395 per stay 40% per stay after your plan deductible
Outpatient hospital services $350 40% after your plan deductible
Ambulatory surgical center $350 40% after your plan deductible
Doctor visits
Primary care physician (PCP) $10 40% after your plan deductible
Specialist $40 40% after your plan deductible
Primary benefits Your costs for in-network care Your costs for out-of-network care
Preventive care $0 0% – 40%
Preventive care includes:

  • Abdominal aortic aneurysm screenings
  • alcohol misuse screenings and counselling
  • Bone mass measurements
  • Breast cancer screening: mammogram
  • Cardiovascular disease screenings
  • Cardiovascular behaviour therapy
  • Cervical and vaginal cancer screenings
  • Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy)
  • Depression screenings
  • Diabetes screenings
  • HBV infection screening
  • Hepatitis C screening tests HIV screenings
  • Lung cancer screenings
  • Nutrition therapy services
  • Obesity behavior therapy
  • Prostate cancer screenings (PSA)
  • Sexually transmitted infections screenings and counseling
  • Tobacco use cessation counselling
  • Vaccines: Covid-19, flu, hepatitis B, pneumococcal
  • Welcome to Medicare preventive visit
  • Yearly wellness visit
Lower cost sharing out-of-network; for Covid-19, influenza, pneumonia, and Hepatitis B vaccines

Higher cost sharing out-of-network: for all other Medicare-covered preventive services

Emergency & urgent care
Emergency care in the United States $90
Urgently needed care in the United States $40
Emergency & urgently needed care worldwide Emergency care: $90

Urgently needed care: $90

Ambulance: $300

Diagnostic testing
Diagnostic radiology

(e.g. MRI & CT scans)

$295 40% after your plan deductible
Lab services $40 40% after your plan deductible
You will pay $0 for certain lab services such as urine protein, hemoglobin A1c, prothrombin (protime) and urine albumin.
Diagnostic tests & procedures $40 40% after your plan deductible
Outpatient x-rays $40 40% after your plan deductible
Hearing, dental, & vision
Diagnostic hearing exam $0 40% after your plan deductible
Routine hearing exam $0 40% after your plan deductible
We cover one exam every year. All appointments need to be scheduled through NationsHearing.
Hearing aids The plan pays up to a maximum amount of $1,250 per ear, every year. You have the responsibility to any costs over this amount.
NationsHearing will manage your hearing aid benefits. All hearing aids need to be bought through NationsHearing.
Dental services (in

addition to Original

Medicare coverage)

$0 for preventive services (e.g.

oral exam, x-rays and cleaning)

$0 for comprehensive services

(e.g. fillings and extractions)

20% for preventive services (e.g.

oral exam, x-rays and cleaning)

 

20% for comprehensive services

(e.g. fillings and extractions)

The plan pays up to $750 every year for services which are covered. Cosmetic services like teeth whitening, are not covered. You have the responsibility for any costs over this amount.

 

This plan utilizes the Aetna Dental® PPO Network. You are able to see in- or out-of-network providers for dental services. It is important to note that most out-of-network providers will bill Aetna directly. If you use one who won’t bill them, you are able to pay for covered services and ask Aetna to reimburse you.

The information in the table above is not complete, if you want to see the complete version, you are able to access here because the information in the table above is based on it.

Leave a Reply

Your email address will not be published.